<!DOCTYPE html>
<html lang="en">
<head>
    <meta charset="UTF-8">
    <title>Title</title>
</head>
<body>
<form class="layui-form" lay-filter="updateForm" id="update_user_form" action="" style="padding:15px 10px;">
    <input type="hidden" name="id">
    <div class="layui-row">
        <div class="layui-col-xs3">
            <label class="layui-form-label">病历号</label>
            <div class="layui-input-block">
                <input type="text" name="disoddid" required  lay-verify="required" placeholder="患者" autocomplete="off" class="layui-input">
            </div>
        </div>
        <div class="layui-col-xs3">
            <label class="layui-form-label">患者姓名</label>
            <div class="layui-input-block">
                <input type="text" name="rname" required  lay-verify="required" placeholder="患者" autocomplete="off" class="layui-input">
            </div>
        </div>
        <div class="layui-col-xs3">
            <label class="layui-form-label">主治医生</label>
            <div class="layui-input-block">
                <input type="text" name="medid" required  lay-verify="required" placeholder="患者" autocomplete="off" class="layui-input">
            </div>
        </div>
        <div class="layui-col-xs3">
            <label class="layui-form-label">就诊日期</label>
            <div class="layui-input-block">
                <input type="text" name="retime" required  lay-verify="required" placeholder="患者" autocomplete="off" class="layui-input">
            </div>
        </div>
    </div>

    <table class="layui-table">
       <thead>
            <tr>
                <th>费用明细</th>
                <th>小计</th>
            </tr>
       </thead>
        <tbody>
            <tr>
                <td>合计</td>
                <td><input type="text" name="fee" required style="border: 0px;"  lay-verify="required" autocomplete="off" class="layui-input"></td>
            </tr>
            <tr>
                <td>总计</td>
                <td><input type="text" name="fee" required style="border: 0px;"  lay-verify="required" autocomplete="off" class="layui-input"></td>
            </tr>
        </tbody>
    </table>
</form>
</body>
</html>